How to manage blood glucose levels in a patient with type 2 diabetes, Polycystic Ovary Syndrome (PCOS), and scleroderma on Basaglar (insulin glargine) 65 mg, who is starting steroid therapy?

Managing Blood Glucose in Type 2 Diabetes with PCOS and Scleroderma During Steroid Therapy

For a patient with type 2 diabetes on Basaglar (insulin glargine) 65 mg who is starting steroid therapy, the most effective approach is to add NPH insulin to their regimen, administered at the same time as the steroid dose, while maintaining their basal insulin glargine. 1

Understanding Steroid-Induced Hyperglycemia

Glucocorticoids significantly impact glucose metabolism by:

• Inducing hyperglycemia in 56-86% of patients with and without pre-existing diabetes 1
• Causing disproportionate daytime hyperglycemia with relatively normal overnight glucose levels 1
• Increasing mortality and morbidity risk if left untreated, particularly from infections and cardiovascular events 1

Insulin Management Algorithm

Step 1: Maintain Basal Insulin

• Continue Basaglar (insulin glargine) 65 mg at the same time daily
• Do not reduce the dose initially, as the patient will need this for overnight coverage 2

Step 2: Add Intermediate-Acting Insulin

• For short-acting steroids (e.g., prednisone):

  • Add NPH insulin at the same time as steroid administration 1, 3
  • Initial dose: 0.1-0.3 units/kg based on steroid dose 1
  • NPH action peaks at 4-6 hours, matching the peak action of intermediate-acting steroids 1

• For long-acting steroids (e.g., dexamethasone):

  • Consider increasing the basal insulin (Basaglar) dose by 20-30% 1, 3
  • May require multiple daily NPH doses if on continuous steroid therapy 1

Step 3: Add Prandial Coverage

• Add rapid-acting insulin before meals 1
• Initial dose: 4 units per meal or 10% of the basal dose 3
• Increase prandial insulin by 40-60% from baseline requirements due to steroid effect 1

Step 4: Implement Correctional Insulin

• Add correctional insulin every 4 hours with rapid-acting insulin 1
• Use a more aggressive correction scale than standard 1
• Target blood glucose range: 100-180 mg/dL 1

Blood Glucose Monitoring

• Monitor blood glucose at least 4 times daily (before meals and at bedtime) 3
• For inpatients, consider more frequent monitoring (every 4-6 hours) 1
• Pay particular attention to afternoon and evening values, which are most affected by morning steroid doses 1

Daily Dose Adjustments

• Adjust insulin doses daily based on blood glucose patterns 1
• Increase NPH dose by 20% if afternoon/evening glucose remains elevated 4
• Reduce NPH dose by 20% if hypoglycemia occurs 3
• Anticipate changing insulin requirements as steroid doses change 1

Special Considerations for This Patient

PCOS Considerations

• Patients with PCOS often have increased insulin resistance
• May require higher insulin doses than typical patients with type 2 diabetes
• Monitor for signs of ovarian hyperstimulation if fertility medications are also being used

Scleroderma Considerations

• Assess for skin thickening at injection sites which may affect insulin absorption
• Rotate injection sites carefully to ensure consistent absorption
• Consider shorter needle lengths (4mm) to avoid unpredictable absorption 3

Common Pitfalls to Avoid

1. Using only basal insulin adjustment: This is insufficient as steroids primarily affect postprandial glucose levels during the day 4

2. Failure to match insulin timing with steroid pharmacokinetics: NPH insulin should be timed to match the peak action of steroids 1, 4

3. Overlooking the need for daily adjustments: Steroid-induced hyperglycemia requires frequent monitoring and dose adjustments 1

4. Nocturnal hypoglycemia: Over-aggressive insulin dosing can cause overnight hypoglycemia as steroid effects wane 5

5. Delayed recognition of hyperglycemia: Begin monitoring immediately when steroids are started, don't wait for symptoms 6

By implementing this structured approach with NPH insulin added to the patient's existing Basaglar regimen, along with appropriate prandial coverage and frequent monitoring, steroid-induced hyperglycemia can be effectively managed while minimizing the risk of hypoglycemia.